Sunday, August 5, 2007

One down, one to go...

It’s Sunday afternoon and Elizabeth and I are on our 2nd day of call for the weekend. Yesterday (Saturday) we were handed the OB, ICU and Medicine services to cover after all of the doctors on site came in for rounds in the morning. That consists of about 55 patients, not including post partum patients. We don’t have to see all of the patients but we are responsible to cross-cover for them.
The morning started out slow, we rounded leisurely on our 7 patients we had on our service before starting call. Within an hour of finishing rounds we were summoned to see a 26 y.o. woman with AIDS who was being cared for by another family physician here. She was puffy with excess fluid (anasarca), short of breath and very hypoxic. I scanned her old X-ray from the day before and saw the large pleural effusion compressing her right lung. We ordered a STAT XR of her chest and in less than an hour we saw that her right chest was nearly obliterated. Elizabeth did the pleural tap and we started to drain fluid. At 500cc’s of fluid running into our collection bag, the ER paged us, and at 1000cc’s Elizabeth went down to start consulting on the ER patients. At 1500cc’s, I was paged to the ICU, but wanted to get off all the fluid we could for this very sick lady with AIDS. Finally at 2000cc’s I pulled the catheter and headed off to the ICU. The patient was breathing much easier the rest of the day and evening, but was still terribly sick. She died early this morning.
The 3 day old lay in the ICU bed looking jaundiced and limp. Dr. Messner, our outstanding German neonatologist, signed him out to me as “I don’t think we can save this one but we try, yes?”. I hooked up the infected baby to a old German-made CPAP machine with labels that read “Luft” und “Heitzung”, etc.. We were able to get the baby saturating reasonably well but he was pausing his breathing intermittently – a sign he was seriously compromised. His white blood cell count was sky high and his platelets were dropping. Then there was bleeding from inside his stomach and lungs and we were backed into a corner. He needed O-positive blood and at his size, it wouldn’t take much to make up the loss but the infection was taking over. At the same time another ICU patient also needed fresh O-positive blood. Guess who is O-positive? Despite all of the antibiotics, respiratory support, and blood transfusions, he died this morning at 2:20 AM. I sat with the mother and the chaplain and we prayed together shortly before he died. This baby was to be her second child and she had waited 5 years to have this one and was worried she may not carry another baby.
Around this whole story was the car accident with 4 victims, 5 admissions to our service and more ICU care. Dinner break came at 11:30PM, so much better than lunch at 1:30AM like last time. Elizabeth did a great job of triaging her patients and evaluating the trauma victims, sewing up a foot that had a good portion of the sole filleted open, and stepping in on a delivery where she saved the patient from C-section by good insight and management of the labor in culturally challenging circumstances.

Sunday 10 PM
We have enjoyed a completely reasonable call day, the ER was empty a few minutes ago, no one in the waiting area, no one in active labor right now. Elizabeth stepped in to help in a resuscitation and the baby ended up having a large meningomyelocele about 8 cm long. Fortunately, one of the top surgeons in the world who started the Bethany Hospital for children lives here and will begin to repair it tomorrow.
At dinner time, we did a C-section for a term footling breech baby which came out great. It took an hour for the husband of the patient to consent for the C-section. Elizabeth did a beautiful job with the C-section.
Daniel, Jordan and I then raced off to Mama Chiku’s restaurant to get our last dinner in Kenya at the finest dining in Kijabe. It was great to see Mama Chiku and her now adult kids, Kimami and Ruth. Daniel and Jordan have had quite the adventures this past week with Kim and his other friend, John.

I learn so much here and am blessed by the staff and patients here. This morning walking into the hospital, I heard some nurses singing in beautiful harmony from the ward above the entrance. Funny we don’t hear that at home in Seattle. There is much sadness and sickness here but there is also tremendous faith, peace and contentment. I wonder what this place will be like when I return. Will the advances in economics change the people and the medical care so profoundly that we lose the compassion that should drive us? Or will the faith and service of those who are hear act as a catalyst that will bring the best of both worlds – greater medical expertise and compassion- to the same place. I believe the latter will be true. Where God is at work, there is nothing that will overcome his purpose.

Friday, August 3, 2007


Our medicine team has dwindled as we head toward our call weekend where we anticipate that we’ll double the size of our inpatient team to over twenty again. We have had several deaths on our service this past two days. The first was our 53 y.o. with a massive tumor load in his liver who died about 10 hours after we told him the pathology report that showed he had adenocarcinoma, and the second was one woman with AIDS and PCP pneumonia. Fortunately, we were able to send some people home who have recovered from their acute illnesses rapidly. Two patients with congestive heart failure went home this week – one young but with severe mitral regurgitation, and one who was older with cardiomyopathy due to hypertension. On rounds today we went to see a diabetic patient who was having cardiac ischemia just laying there in her bed who had pain for several hours already. Off to the ICU for her, as we treated what looked like an acute infarct when we first got her on a cardiac monitor. On arrival, she became lethargic from a low blood sugar since she had received her insulin but was too ill to eat from her chest pain. The pace of these crises is handled quite differently here – a bit like herding cats.
One great moment this past week was when I gave one of our AIDS patients (M.) a toothbrush that was donated by one of my patients back home to hand out here. She is wasted and quite ill, on treatment for TB and PCP pneumonia and not eating well at all. She had teeth that have been stained by her iron supplementation and had no toothbrush to clean them. She lay gaunt in bed with sunken eyes as we started on examination of her. When we were done, I asked her if she would like a toothbrush and toothpaste to clean her teeth. I gave her the package and had to open the brush packet as she was too weak to do so herself. She looked at our team with a huge smile. Now for the past two days, her smile has graced us each day on rounds as her teeth are getting whiter by the day. Thanks, Mr. and Mrs. Walker, for the gift you gave to M. and many others here. I am not sure if she will survive but she has known compassion and caring from strangers in a far away land. If she can pull through and get on HIV treatment, she may live a long life, but we must get her through this critical illness first. Only God knows if that will happen but we are determined to give it our best effort.